How a State Advances Whole-Person Health Care

In my position as Pennsylvania’s Secretary of Human Services, I’ve thought a lot about the many factors that contribute to a person’s health, and about the role of managed care organizations and health care providers in helping patients to access food, housing, education, and employment services. This is a conversation happening around the country, as we collectively realize that a person’s health — and health care spending — are impacted by so much more than what happens in a doctor’s office. If we want to deliver efficient, effective health care, we can’t ignore the social and environmental factors known as social determinants of health.

When someone presents at an emergency department, doctor’s office, or treatment facility, it’s critical that we consider the whole person’s health needs. If we simply treat the immediate medical problem, we risk sending them back to an environment that created or exacerbates their health issues. By not looking more broadly at the person’s social, emotional, economic, and educational circumstances, we may be missing opportunities to address underlying contributors to disease, as well as opportunities to reduce future health care spending.

If we want to deliver efficient, effective health care, we can’t ignore the social and environmental factors known as social determinants of health.”

So, how can we help patients achieve better health, when better health requires more than just access to medical care?

The health care system can’t, and shouldn’t, meet every social need, as Yale Economics Professor Fiona Scott Morton pointed out in a NEJM Catalyst interview last year. But, we must be able to rely on providers to routinely screen their patients for these social determinants of health. This means not just when it’s convenient or when providers have time; it means making these screenings as commonplace as collecting vital signs. They should then refer patients to appropriate social services and be engaged partners, much like primary care physicians who regularly coordinate care with specialists. We don’t expect clinicians to be experts in each environmental stressor, but they should know about key resources in the community — from food pantries to job training programs — that can be part of a referral network.

For example, in Pennsylvania, we have a “warm hand-off” program that transfers overdose survivors directly from an emergency room to a drug treatment facility to improve their prospects for recovery. Additionally, our health care system is moving to better identify individuals with mental health issues and subsequently refer them to appropriate care. Within our Medicaid population, for instance, we have seen a measured increase in postpartum depression screening, referral, and treatment over the last 2 years.

A State’s Twofold Role

I see the state’s role in advancing whole-person care as twofold. First, we need to lead the movement toward value-based payments so that we’re paying for outcomes and incentivizing providers to keep people healthy. In this model, it starts to make sense for clinicians to talk with their patients about the root causes of poor health, which often include social and environmental factors.

The state should be a catalyst for linking health care providers with community-based organizations that address social determinants of health.”

Second, the state should be a catalyst for linking health care providers with community-based organizations that address social determinants of health. In Pennsylvania, we are working closely with these entities to develop a statewide online resource and referral tool that will allow providers to connect patients seamlessly to appropriate resources. We convened about 60 health care and social services organizations to discuss the tool, brought in 13 vendors to demo their technology, and will soon hire a company to develop it. There is a lot of excitement across sectors for this approach. This is a heavy lift and will take a few years to fully implement, but the benefits of better coordination of care, information sharing, and ability to track outcomes are worth the state’s investment to put this collaborative hub technology in place.

Innovation Tour

During 2018, I traveled across Pennsylvania on a “Medicaid Innovation Tour” to see firsthand the creative ways that our managed care organizations are partnering with community-based groups to address housing, food insecurity, transportation, and other needs that impact their members’ well-being, as well as Medicaid health care spending. Pennsylvania’s rich diversity shows that a one-size-fits-all approach to promoting whole-person care won’t work for all communities. Indeed, I saw the value of working with social services organizations that understand the unique needs of their local residents. Although the approaches may look different from community to community, the goal is to use technology and relationship-building to effectively improve the health outcomes of the people we serve.

One of the most promising innovations I saw was a partnership between Metropolitan Area Neighborhood Nutrition Alliance (MANNA) and each of our managed care organizations to provide medically tailored meals to individuals with life-threatening chronic conditions, many of which are caused or exacerbated by poor diet and nutrition. These are critical alliances, as chronic illness affects more than 60% of Pennsylvania residents and accounts for more than 80% of health care costs.

For a group of seriously ill and nutritionally at-risk MANNA clients, average monthly health care costs were 31% lower, inpatient hospital stays were 37% shorter, and the number of hospital admissions was cut in half, compared to Medicaid patients without MANNA services.”

In addition to delivering meals for the entire family, MANNA provides nutritional counseling and meal planning and preparation classes that promote overall health. Staff of the managed care organizations told me that members served by MANNA were better able to control their diabetes and had reduced medical costs, and that they hoped to expand the partnership. A 2013 study published in the Journal of Primary Care & Community Health bore this out. For a group of seriously ill and nutritionally at-risk MANNA clients, average monthly health care costs were 31% lower, inpatient hospital stays were 37% shorter, and the number of hospital admissions was cut in half, compared to Medicaid patients without MANNA services.

Homelessness and job insecurity can also contribute to poor health. During another Innovation Tour visit last year, we witnessed how Health Partners Plans (a managed care organization) had teamed up with the nonprofit Ready, Willing & Able to provide job-readiness training to help homeless men reenter the workforce. For example, Health Partners Plan hosted a day of workshops aimed at strengthening participants’ professional skills around resume building, interviewing skills, and the like.

Our state has spurred managed care organizations to consider ways they can assist their members with education, training, or employment resources. Several have programs to help members attain their high school equivalency diploma, and many partner with community-based entities that provide job training or other career readiness services. Some have programs aimed at hiring individuals who have experienced significant employment barriers and helped people transition off public assistance. Efforts by managed care organizations to support unemployed or underemployed individuals are especially pressing in light of ongoing discussions at the federal level and in several states (including Pennsylvania) around establishing work requirements for Medicaid recipients.

Efforts by managed care organizations to support unemployed or underemployed individuals are especially pressing in light of ongoing discussions at the federal level and in several states (including Pennsylvania) around establishing work requirements for Medicaid recipients.”

In the area of housing, the UPMC health plan is partnering with the nonprofit Community Human Services in Pittsburgh to scale up a program that connects homeless people with stable housing to help improve their health and lower medical costs.

States have a unique ability to convene and coordinate large groups of individuals with diverse interests toward achieving a shared objective. In Pennsylvania, we’ve learned that the state plays a critical role in moving the health care system forward. Through our managed care organizations, we are working on creating standardized assessments for social determinants of health for providers, enhancing community-based programs that help patients manage their chronic conditions, and expanding investments in technology solutions to meet the needs of the people we serve.

In a health care system that rewards better health, providers have incentives to be more efficient and effective with their care, but also to look beyond the condition that brought a patient to them initially. When we focus on the whole person, including their social and environmental circumstances, we are more likely to keep people healthy so that they can avoid future medical crises and costs. By doing so, we will begin to bend the growing cost curve and stabilize health care spending.

Teresa Miller, JD

Secretary of the Pennsylvania Department of Human Services

Discuss

Your email address will not be published. Required fields are marked *

Comment

Name *

Email *

Save my name and email in this browser for the next time I comment.

Your email address will not be published. Required fields are marked *

Note: This is a moderated forum and all comments are reviewed before posting. By clicking on the "Post Comment" button below, you agree to abide by the NEJM Catalyst Terms of Use. We reserve the right to not post every comment; including those that are submitted anonymously or that are potentially illegal, vulgar, libelous, or commercial in nature.

Ron Halbrooks

Teresa,

This is Ron Halbrooks and I do Internal Medicine and Geriatrics in the Duke Health System.

The Memphis Health system in a coalition with churches has reduced hospitalizations and saved 2-3 million dollars a year in this coalition.

I think leaving the communities of faith out of this discussion is lacking.

July 06, 2019 at 6:51 pm

Reply

Name *

Email *

Comment *

Save my name and email in this browser for the next time I comment.

Your email address will not be published. Required fields are marked *

Note: This is a moderated forum and all comments are reviewed before posting. By clicking on the "Post Comment" button below, you agree to abide by the NEJM Catalyst Terms of Use. We reserve the right to not post every comment; including those that are submitted anonymously or that are potentially illegal, vulgar, libelous, or commercial in nature.

Doug Tynan, PhD

I think this is a great start and highlights that approaching social factors of health requires work at the county or state level and cooperation of a number of agencies and organizations, including faith based groups, other non-profits, for profit business (e.g. grocery stores, transportation services), with a focus on health. a Collective Impact approach could help groups learn to focus on the important variables and find common goals. When I was with Nemours Health and Prevention, we spent a lot of money with small improvements in Delaware, but more importantly learned how to get disparate groups to find their common goal (s) and work together.

July 12, 2019 at 1:51 pm

Reply

Name *

Email *

Comment *

Save my name and email in this browser for the next time I comment.

Your email address will not be published. Required fields are marked *

Note: This is a moderated forum and all comments are reviewed before posting. By clicking on the "Post Comment" button below, you agree to abide by the NEJM Catalyst Terms of Use. We reserve the right to not post every comment; including those that are submitted anonymously or that are potentially illegal, vulgar, libelous, or commercial in nature.

If envisioned and implemented properly, a partnership between clinical delivery systems and clinical research programs can get us closer to the goal of achieving learning within the care continuum and discovering evidence that is available when it is needed.

Clinician engagement is vital for improving clinical quality and patient satisfaction, as well as the job satisfaction of clinicians themselves. Yet nearly half of health care organizations are not very effective or not at all effective at clinician engagement.

The U.S. health care system may seem broken, but it’s on its way to greatness, according to the authors of Health Care Reboot. They discuss their optimism for U.S. health care reform, particularly on the social determinants of health, payment, consumerism, and technology.

NEJM Catalyst Insights Council members feel that culture change at their organizations is heading in the right direction, but differ on who it should come from, and reveal too much balance between emphasis on bottom line and emphasis on patient care.

Although three-quarters of Insights Council survey respondents say culture change is a high or moderate priority at their organizations, survey results show a lot of work on organizational culture remains to be done.